Experience of non-breastfeeding mothers

Abstract

Background:

Breastfeeding is currently strongly recommended by midwives and paediatricians, and the recommendations are based on documents provided by the World Health Organization and public health authorities worldwide.

Research question:

The underlying question is, how are non-breastfeeding mothers affected emotionally when informed that breastfeeding is the safest and healthiest option?

Research design:

The method used is an anonymous web-based qualitative survey exploring the narratives of non-breastfeeding mothers, published on Thesistools.com. The aim is to achieve qualitative knowledge about the emotions of non-breastfeeding mothers.

Participants and research context:

Participants were based in Sweden, the United Kingdom and the Netherlands and were selected through a purposeful sample.

Ethical considerations:

The online survey anonymizes responses automatically, and all respondents had to tick a box agreeing to be quoted anonymously in scientific articles. The study conforms to research ethics guidelines.

Findings:

Respondents describe how they were affected, and the following themes emerged in studying their descriptions: depression, anxiety and pain, feeling failed as a mother and woman, loss of freedom/feeling trapped, relief and guilt.

Discussion:

The themes are discussed against the background of the ethics of care and a theory of ethically responsible risk communication.

Conclusion:

Three conclusions are made. First, the message should become more empathetic. Second, information should be given in an attentive dialogue. Third, information providers should evaluate effects in a more inclusive way.

Keywords

Bonding breastfeeding non-breastfeeding mothers postnatal depression public health ethics risk communication the ethics of care

Introduction

The message sent by the World Health Organization (WHO), United Nations Children’s Fund (UNICEF) and public health authorities in most countries is that breastfeeding is the optimal way to feed all infants. The documents provided by the WHO and UNICEF strongly affect the message sent by healthcare staff, for example, midwives and paediatricians. There is a difference between high-income and low-income countries regarding the health consequences of not breastfeeding due, for example, to water scarcity. However, the promotion of breastfeeding is prevalent in both high- and low-income societies due to health benefits for babies and mothers.¹ Furthermore, breastfeeding is presented as the risk-free option that will protect and promote both the baby’s and the mother’s health and that it will facilitate bonding between the baby and mother. Bottle-feeding is described as the risky option, and choosing to bottle-feed one’s baby means refraining from doing what is natural and safe, thereby risking the baby’s health.^2,3

The scientific evidence is not as clear as one may think.^3,4 Furthermore, the message is highly value-laden, and information on risks is intertwined with notions of good motherhood.^5–9 Furthermore, there is a group of women who have physiological, emotional and psychological problems with breastfeeding.¹⁰ Against this background, it is crucial to analyse the effects of the current message on those mothers who cannot and/or do not breastfeed.

The aim of this article is to find out more about the experiences of some of these women. The underlying question is, how are non-breastfeeding mothers affected emotionally when informed that breastfeeding is the safest and healthiest option? The method used is an anonymous web-based qualitative survey exploring the narratives of respondents, who were chosen through a purposeful sample. The aim is not to quantify or generalize. The purpose is to achieve qualitative knowledge about the emotions of non-breastfeeding mothers. The results have been analysed to explore general themes and are discussed from an ethical perspective.

The article is structured as follows. First, the current infant feeding message is presented. Second, the methodology used to explore the experiences of non-breastfeeding mothers is described. Third, the findings of the survey, that is, the experiences described by the respondents are presented. The last sections of the article discuss ethical problems of the current policy at three levels: the message, the method of communication and its effects.

Background

Although there are two ways to feed an infant today, that is, through breastfeeding and bottle-feeding, the former is promoted in most countries as the superior method. The WHO and UNICEF promote breastfeeding, declaring that ‘all women should be enabled to practice exclusive breastfeeding and all infants should be fed exclusively on breast milk from birth to 4–6 months of age’.¹ Healthcare staff and medical students receive advice on what to recommend through a model chapter published by the WHO.¹¹ The chapter describes how proper nutrition is essential to growth, health and development and that poor and inappropriate nutrition increases the risk of illness and death. It is also stated that there is evidence that ‘adults who were malnourished in early childhood have impaired intellectual performance’ and that malnutrition in early years may lead to decreased reproductive capacity for women.¹¹ It is noteworthy that the paragraph described is about malnutrition and inappropriate nutrition, that is, not about breastfeeding or bottle-feeding per se. Against that background, the following recommendations are provided:

Exclusive breastfeeding for 6 months (180 days);

Nutritionally adequate and safe complementary feeding starting from the age of 6 months with continued breastfeeding for up to 2 years of age or beyond.

It is stated that infants who are artificially fed have an increased risk of asthma, atopic diseases, type 1 diabetes and childhood leukaemia.¹¹ It is interesting that the term ‘artificially fed’ is used, implying that all choices of nutrition that is not breast milk is unnatural and risky. The WHO¹¹ also states that if a country has many malnourished children, and malnourished is again implicitly equalized with non-breastfed, this has implications for national development.

The WHO and UNICEF introduced the so-called Baby-friendly hospital initiative in 1991. The aim of the programme, implemented by more than 152 countries, is ‘to implement practices that protect, promote and support breastfeeding’.¹² In New York, former mayor Michael Bloomberg implemented the so called ‘Latch on NYC programme’ in 2012. The programme limits hospital staff’s access to formula, stops the distribution of free formula to mothers and prohibits the promotion of formula in hospitals. One of the main messages to hospitals is to refrain from providing formula to infants unless medically necessary, requiring that staff sign out formula like medication.

In the United Kingdom, mothers are told by the National Health Service (NHS) that breastfeeding gives babies the best start in life and that ‘What happens in your baby’s first years has a big effect on how healthy he or she will be in the future’.¹³ Packages of formula in Sweden and the Netherlands carry a message that ‘breastfeeding is the best for your baby’. Manufacturers of substitute formulas are not allowed to market their products.¹⁴ One consequence of this prohibition is that manufacturers of formula do not even provide information on how to prepare formula milk on their websites in Sweden.¹⁵ The only information provided is that they support WHO’s recommendations that breast milk is the best food for infants.

The underlying presumption is that because breastfeeding is the best option, it should be promoted to all new mothers and families. The lack of scientific accuracy and objectivity in the current information has been criticized in several articles.^2,4,17 Breastfeeding has been described as part of an ‘ideology of total motherhood’. The latter, Wolf³ argues, is ‘a moral code in which mothers are exhorted to optimize every dimension of children’s lives, beginning in the womb, and its practice is frequently cast as a trade-off between what mothers might like and what babies and children must have’. As Kukla¹⁶ argues, there are numerous norms which ‘good mothers’ are supposed to live up to. Otherwise, they are punished and shamed. Mothers are treated as risk managers, and reproductive warnings, which are proliferate in contemporary society, single out women as uniquely responsible to ‘make choices that minimize risk for others’.¹⁷

A group of women cannot or do not want to breastfeed, for physiological, psychological, emotional or other reasons.^7,9,18,19 One study indicates that women who had negative experiences of early breastfeeding were more likely to be depressed after 2 months.²⁰ Yet, it is often suggested that all mothers can breastfeed.

In order to get a better understanding of how women who could not and/or did not breastfeed their baby were affected by the current information, a qualitative study was conducted. The results will be discussed below after a description of the methodology.

Methodology

Aim

The aim of the study was to gain knowledge on how non-breastfeeding mothers experience breastfeeding and the discontinuation of breastfeeding. Furthermore, the aim was to understand how these women experienced the advice and information provided by healthcare staff and official information in brochures and websites. The study was narrative and qualitative, aimed at understanding the individual situation of the respondents, that is, not to quantify. To collect information about the experiences of this group of women, an online survey with open-ended questions was published online.

Limitations

There are obvious limitations to the study. It is not representative of mothers or of non-breastfeeding mothers. It could be the case that the mothers who do not care what authorities think about their choices did not opt to participate. In order to generalize, more extensive studies would have to be conducted. However, the point of this study is not to generalize but to explore the individual narratives of the responding mothers.

Participants

The sample was purposeful, that is, only aimed at those mothers who could not and/or did not breastfeed. The only criterion for participating was that they could not or did not breastfeed their baby.

Data collection

Data were collected in 2012–2013 through a web-based qualitative and narrative survey using an online survey tool called Thesistools.com. Two surveys titled ‘Emotional experiences of non-breastfeeding mothers’ were published on Thesistools.com. The only difference between the two surveys was that the first survey did not ask in which country the respondent was based when having babies and the second one included that question. In the survey, the respondents were asked questions concerning their experiences of trying to breastfeed and stopping to breastfeed. They were also asked about the information that was provided about breastfeeding and bottle-feeding and how the verbal and written information made them feel. The survey questions are included in an online supplementary appendix.

The link to the survey was published on a Swedish Facebook group for non-breastfeeding mothers called Rätten av välja-amma/flaska (The right to choose breastfeeding/bottle) and a UK-based website for mothers, Mumsnet. It was also provided to a paediatric nurse and to colleagues in the Netherlands for distribution among Dutch non-breastfeeding mothers. The responses in Swedish and Dutch have been translated by the author and a colleague.

Although it is not always easy to differentiate between different causes of emotions when someone is in such a vulnerable situation as after a delivery, the survey separated between questions concerning emotions due to breastfeeding, the discontinuation of breastfeeding and the advice and information provided.

Ethical considerations

The online tool for creating online surveys automatically anonymized the responses. All respondents were asked the question ‘Do you approve of being quoted in scientific articles anonymously? Yes/No’. All respondents answered yes to that question. In Sweden, there is no requirement to request ethical approval for this kind of study. The study conforms to research ethics guidelines.

Results

The five respondents in the first version are all based in Sweden, as the link had only been published in Sweden. Four out of five replied in Swedish and one replied in English. The second survey got 42 responses. A total of 24 of these stated that they gave birth in Sweden and got their information in Sweden. Seven respondents stated that they gave birth and received information in the United Kingdom. Four women stated that they gave birth in the Netherlands. Three of these women received their information in the Netherlands and one received her information in Belgium. Only one respondent in the second survey did not provide details concerning which country she gave birth in, but she replied in Swedish.

All but four women tried to breastfeed at first because they wanted to and/or because it was expected of them. Almost all of the mothers had received information about infant feeding verbally from midwives and doctors as well as written information in booklets and on websites. Most women felt that the information received strongly favoured breastfeeding.

After having studied the responses written by the women, a number of themes arose, the most salient being the following:

Depression, anxiety and pain;

Feeling failed as a mother and woman;

Loss of freedom/feeling trapped;

Relief and guilt.

Data analysis: the emotions of non-breastfeeding mothers

In the following, the responses of the non-breastfeeding mothers who participated in the survey are described and discussed. A qualitative content analysis was made. Four themes emerged as shared by many non-breastfeeding mothers, and they reoccurred in responses to different questions. The emotions involved appear to be related both to how they felt when trying to breastfeed and stopping and to the way the norm of breastfeeding was communicated to them by healthcare staff and official information. The themes are discussed in the following.

Depression, anxiety and pain – feeling like a failed mother

When asked how they felt when trying to breastfeed, many women explain that they experienced mixed emotions. Several respondents state that they had negative emotions because they were in pain and because they were surprised and overwhelmed by the difficulties. At the same time, many women describe that they wanted to continue trying despite the problems because they were told it was the best option.

The most salient theme involves emotions related to depression, sadness and anxiety. Most respondents have negative emotional experiences of trying to breastfeed, discontinuing breastfeeding and the advice provided by healthcare staff and official information on infant feeding. Many women describe how they felt pressured to continue and how they felt ‘like a failure’ or ‘like a bad mother’. They also use words like ‘inadequate’, ‘deviant’ and like they let their child down, probably risking their baby’s health.

Others state that they did not have enough milk and were being ‘connected to machines’ at the hospital to try to get them to produce milk. Throughout this, they were continuously told that breastfeeding is the best thing. One of these women describes breastfeeding as ‘a nightmare’ and the most important cause of her postnatal depression. Another respondent felt ‘heartbroken’ due to her supply problems and states that she was told that everyone could breastfeed if they only tried.

One of the most vivid emotional stories is the following:

I felt awful, my daughter was crying, she didn’t eat enough, lost weight, I panicked all the time and didn’t know what to do. The child health center told me the problem was mine, I did something wrong, that is why she did not gain weight I had to breastfeed even more and weigh my daughter several times a week. During this time I got mastitis in one breast and was adviced to breastfeed like crazy even though I was constantly crying due to the pain. No one saw me, no one helped me, and everyone was just nagging about how good it is to breastfeed.

Relief and guilt

In response to the questions relating to the discontinuation of breastfeeding, many women describe how they harboured both positive and negative emotions. They felt relieved, but also very guilty. As one mother describes it, ‘When I decided to quit it was with sadness in my heart, but at the end it was the best for my son’.

Several women were worried that they might hurt their babies when bottle-feeding them and they felt guilty. The guilt feelings were exacerbated by the way the breastfeeding norm was communicated by healthcare staff. They describe how they were told or made to feel like breastfeeding is the best or only option. They felt questioned and forced to continue, and one woman writes that she hesitated to go to the public preschool because she was ashamed.

As one mother explains it, ‘A bad mother is what I felt like, because you SHOULD breastfeed that is just how it is’. Another respondent worried, ‘Each time we gave our baby formula I thought “what if she gets ill, fat etc”’.

One respondent describes how she felt guilty not merely because she stopped breastfeeding but because she did not enjoy breastfeeding. Arguably, there is a double guilt infusion here: some women feel guilty for not breastfeeding and for not enjoying breastfeeding. They appear to think that they are not allowed to feel good and that they ought to be ashamed of themselves for not breastfeeding.

For many women it was an extremely difficult decision to stop breastfeeding. One woman describes it as the hardest decision in her life, that it hurt so much that it still makes her cry. Another woman describes it as difficult because she questioned herself as a ‘real mother’ and she worried that her child might get allergies. But after a few months, she started to feel better because her relationship with the baby improved and the parental leave got so much better once she stopped.

One respondent describes a situation in which she was made to feel guilty by healthcare staff:

One of the worst things I experienced actually happened in a group meeting for new parents at the local child health center. The new mothers were supposed to sit in a ring with our 2-months old babies and tell the others about ourselves, about the delivery and breastfeeding. ‘Well, that’s nice to have to “out” oneself like that’, I thought, but I decided not to say anything about breastfeeding when it was my turn. Of course, the lady asked me about breastfeeding and I say we don’t breastfeed. I added quickly that ‘it didn’t work for us’. The other mothers had told us about their struggle with breastfeeding and mastitis and God knows what but they ‘kept struggling’ and certainly ‘didn’t give up’. Unlike me then. Then, the lady in charge turns to me (some midwife), tilted her head and says to me in front of everyone: Well, you have heard how everyone in here keep struggling with the feeding and I’m tooootally convinced that you would have succeeded breastfeeding if you would have kept struggling. I was completely stunned. And didn’t say anything. And she keeps asking in front of everyone if I had enough support from my husband or if HE was the one who was negative? I was so angry, but at the same time it felt wrong to start arguing about it then and there. But I regret that like hell today, honestly. Had it been today, I would have really told her off. And in the middle of all this, THIS is the saddest part, that you are so exposed when you need the most support and encouragement.

Some women had a supportive and caring midwife or paediatric nurse, but many respondents explain that they received inadequate information. One mother states, ‘When no one talks about formula, and the paedriatric nurse says that she cannot “promote” formula, you feel like a criminal, like you are doing something illegal’. Another respondent says her informed choice was not respected, when the midwife called her up trying to convince her to breastfeed her next child and asking whether she was ‘sure’ she wanted to stop.

Bonding problems

Some women suffered from postnatal depression and/or had difficulties bonding with their baby, and some felt rejected by their child or started to associate the baby’s being hungry and crying with physical pain. For these women, the problems associated with breastfeeding made the situation worse.

Several women describe how their relationship with the baby was obstructed by the breastfeeding problems or the way they were treated by midwives and nurses. One woman describes how she felt that healthcare staff was solely interested in the baby’s wellbeing and did not care about her wellbeing or the fact that she experienced a crisis (postnatal depression). She also describes her bonding with the baby as severely obstructed by her problems with breastfeeding, and she now regrets not having stopped earlier because the bonding got so much better once she stopped breastfeeding.

One respondent writes that she often got angry when the baby was hungry because that meant she ‘had’ to breastfeed. When she stopped, she felt like a bad woman and mother, she says.

Another respondent describes how she pretended that her baby was not hungry despite crying ‘and didn’t start to feed him until he was hysterical’.

Feeling trapped – losing one’s freedom

Some women did not enjoy breastfeeding at all. One woman describes how she felt when trying to breastfeed as follows: ‘Trapped, disgusted, in pain, anxiety/angst’.

Several respondents describe how they felt like they lost their freedom and felt trapped when breastfeeding. One mother states that she felt like a freer and happier person when she stopped.

In addition to feeling trapped by breastfeeding, some women are burdened by the advice given and the way it is provided. One woman writes that she stopped believing the midwives or health visitors when she decided to stop breastfeeding and got back in control.

Discussion

This study indicates that some mothers who have problems breastfeeding are severely affected, get depressed and feel guilty because they stop breastfeeding. It is of course difficult to disentangle the causes and know what is due to their own situation and personality and what is due to the way the risks and benefits are being communicated by healthcare staff and people around them. However, the majority of the respondents felt that they were told that breastfeeding was the best option and that they did not receive adequate information and/or support about bottle-feeding. The result appears to be a lack of self-esteem for this group of new mothers. This is the opposite of what could reasonably be expected from midwives, paediatric nurses and doctors and even the authorities informing new parents. From a normative perspective, institutions and people providing information to individuals who recently had the life-changing experience of becoming a parent should be based on care and empathy. Parents should be supported in their new role. Although most healthcare providers would agree, this study illustrates the unintentional effects of such care. Arguably, the norm to breastfeed infants should not be prior to care and empathy. Ethicists of care argue that attention to the needs of others and responding to those needs are fundamental to morality.^21

–24 There are good reasons to claim that this should be fundamental to the care provided to new parents and families. However, the experiences shared by the respondents indicate that in many cases this is the reality.

The goal in many countries is to increase or maintain breastfeeding numbers. There is a risk that the experiences of non-breastfeeding women are not taken seriously if infant feeding is solely analysed from a quantitative perspective. The experiences of this group of women are ethically important and should inform policy. Current information concerning infant feeding is essentially a form of risk communication in which new parents are informed about the risks and benefits of breastfeeding and bottle-feeding. It is reasonable to demand that ethically responsible risk communication fulfils three conditions. The reason for this is that communication about risks involves three levels. There is a message, a procedure through which the message is communicated and there are effects. All of these levels are ethically relevant and should be scrutinized in order to achieve ethically responsible risk communication. Thus, responsible risk communication should have an ethically acceptable message and procedure. Furthermore, the effects should be ethically evaluated.²⁵ The results from this study illustrate the importance of revising current infant feeding communication against the background of these conditions. In the following, the study is discussed from the perspective of this notion of responsible risk communication. In addition, insights from the ethics of care are used to shed light on the need to improve infant feeding information.

Message based on individual risk-weighing

Infant feeding information is essentially about communicating risks and benefits about breastfeeding and bottle-feeding. That information is based on a calculation regarding such risks and benefits. There are generally two risk-weighing principles. In clinical practice, risks and benefits are commonly weighed in relation to one and the same individual, that is, whether a particular individual should be advised to take a certain medication depends on the risk–benefit ratio to that individual. In contrast, in large-scale societal projects, a collectivist risk-weighing principle is used whereby risks and benefits are weighed collectively. If the sum of all benefits outweighs the sum of all risks, the option is chosen.²⁶ Public health is a peculiar hybrid between the risk-weighing principles. Risks and benefits are calculated collectively, but health is ultimately and fundamentally an intimate personal matter.

Public health is utilitarian, aimed at maximizing utility, that is, the health of the population. As a utilitarian project, it is only concerned with population-based effects in terms of collective risks and benefits. Infant feeding information is based on the public health policy to promote breastfeeding because of its benefits.

When midwives and nurses are told to inform individual mothers of the benefits and risks associated with infant feeding, they are not encouraged to pay attention to individual contextual aspects. The numbers indicating that the risks of bottle-feeding are greater than the risks of breastfeeding (although there is a selection regarding which risks and benefits should be included in the calculation) are used to convince individual mothers and fathers that they should choose breastfeeding.²⁷

The experiences shared by the non-breastfeeding mothers responding to the survey illustrate the ethical problems associated with public health policy. Despite the good intentions of public health, there are ethically problematic consequences for a group of women. How to feed one’s baby is a highly intimate and complex decision, which should be made individually. As the woman quoted above described it, ‘No one saw me, no one helped me, and everyone was just nagging about how good it is to breastfeed’.

There are no neutral ways to present risks, and the framing of risk messages affects how people react.^28,29 The experiences of the respondents illustrate the need to frame infant feeding in an empathetic, caring and context-sensitive way.

One-way information should be replaced by dialogue

In addition to an empathetic message, attention should be paid to the procedure, that is, how information is being communicated. The advice is currently seen as a one-way transmission of information. The underlying idea is that authorities and medical staff should tell people what the best option is. Instead, the delicate situation new parents are in suggests that a dialogue should be initiated where new parents are encouraged to express their thoughts, emotions and concerns. Advice should be given in dialogue with parents. Research in risk communication supports the idea that the procedure is legitimate and invites stakeholders to a dialogue.²⁵

Public health campaigns generally challenge respect for individual autonomy.³⁰ There is an interesting tension between medicine, in which individual autonomy is the core value, and public health, which is essentially a challenge to the same value. A compromise would at least include attentive dialogue instead of authoritative one-way recommendations and prohibitions. The potentially paternalistic nature of public health and the permissibility of persuasive campaigns have been intensely debated.^31,32 Although a central question, paternalism is not the issue here. The point made here is that communication should be attentive, empathetic and based on a dialogue.

We can see that many non-breastfeeding mothers do not feel seen or heard, that they feel sad, depressed and angry. Many women felt like failed mothers who were not doing the best for her baby or even causing harm to their babies. These negative emotions are probably caused by a complex combination of wanting but failing to breastfeed, norms concerning motherhood and the pressure of information and healthcare providers. The way these women feel obviously affects their sense of trust towards healthcare institutions. As one mother describes it, she stopped believing the midwives or health visitors when she decided to stop breastfeeding and got back in control.

Whether the major cause of these women’s negative emotions is the fact that they cannot breastfeed or the way they are being treated by healthcare providers does not matter substantially. Even if the major cause would be the unsuccessful breastfeeding, the information and care should be empathetic, attentive and understanding. It follows that the current one-way information needs to be replaced by a two-way attentive and caring communicative practice.

Ethical evaluation of effects

If breastfeeding is seen as a way to maximize public health, the effects of public health information are measured statistically in terms of how many mothers breastfeed their infants.³³ The experiences shared by the respondents indicate that evaluation of infant feeding communication should take other effects into account. It is useful to analyse the effects of breastfeeding information against the background of the ethics of care. As the statement presented above illustrates, ‘No one saw me, no one helped me, and everyone was just nagging about how good it is to breastfeed’. The core of care is to be attentive to the needs of other human beings.^21

–24 Clearly, this woman did not experience that healthcare staff cared about her needs. The focus of the current information is to inform mothers about the advantages of breastfeeding. Instead, it could reasonably be argued, the focus should be to listen, be attentive and respond to the needs of the mother (the father) and baby. The ethics of care emphasize the relational aspect of moral life and that it is not care if the cared-for does not experience care.^23,24 This means that good intentions are inadequate. If communication between healthcare providers and new families is seen as relational, the needs and emotions of the latter come to the fore. This may in some cases imply advice that bottle-feeding is preferable. It requires sensitivity to the specific situation, the specific individual and her needs.

Furthermore, the health and wellbeing of babies are obviously very closely connected to the health and wellbeing of the mothers. Clearly, we cannot ask infants whether they feel cared for by the current policy. However, mothers and fathers could be invited to a dialogue. Even if the majority would feel cared for by the current policy, from an ethics of care perspective the experience of the minority should be taken into account. In another medical context, end-of-life-care, the notion of ‘compassionate truth-telling’ has been suggested as a way to talk to end-of-life-patients about dying.³⁴ Although a different context, there are good reasons to adopt the notion of compassionate truth-telling when communicating with vulnerable people like new mothers (and fathers).

Conclusion

The experiences of non-breastfeeding mothers shed light on the ethical problems of current care for new mothers. A group of mothers get depressed and feel like blameworthy and inadequate mothers. Despite the limitations concerning generalizability, the study should be used as a starting point for conducting larger studies of the effects of the current breastfeeding norm in healthcare. In addition, it indicates that the way infant feeding risks and benefits are currently communicated, by professionals and institutions, should be revised. As ethicists of care argue, a practice or relationship is not caring unless the recipient experiences that she is cared for.

Footnotes

Acknowledgements

First of all, I would like to express my gratitude to the women who shared their stories. This article has benefited substantially from discussions with colleagues at Delft University of Technology and Uppsala University. I would especially like to thank Sabine Roeser and Anna T Höglund. In addition, I would like to thank Claire Stolwijk for invaluable advice on the design of the survey and paediatric nurse Emilie Nilsson, who helped distribute the link to the survey. I would also like to thank two reviewers for very constructive comments.

Funding

This research was partly conducted under Sabine Roeser’s NWO (Netherlands Organisation for Scientific Research) VIDI-grant, number 276-20-012.

Note

References

WHO/UNICEF. Innocenti declaration on the protection, promotion and support of breastfeeding, http://www.unicef.org/programme/breastfeeding/innocenti.htm (1990, accessed 11 August 2014).

Murphy

. Risk, responsibility, and rhetoric in infant feeding. J Contemp Ethnogr 2000; 29(291): 291–325.

Wolf

. Is breast really best? Risk and total motherhood in the National Breastfeeding Awareness Campaign. J Health Polit Policy Law 2007; 32: 595–636.

Wolf

. Is breast best? Taking on the breastfeeding experts and the new high stakes of motherhood. New York; London: New York University Press, 2011.

Nihlén Fahlquist

Roeser

. Ethical problems with information on infant feeding in developed countries. Public Health Ethics 2011; 4(2): 192–202.

Knaak

. Contextualising risk, constructing choice: breastfeeding and good mothering in risk society. Health Risk Soc 2010; 12(4): 345–355.

Blum

. At the breast: ideologies of breastfeeding and motherhood in the contemporary United States. Boston, MA: Beacon, 1999.

Kukla

. Ethics and ideology in breastfeeding advocacy campaigns. Hypatia 2006; 21: 157–181.

Law

. The politics of breastfeeding: assessing risks, dividing labor. J Women Cult Soc 2000; 25: 407–447.

10.

Kelleher

. The physical challenges of early breastfeeding. Soc Sci Med 2006; 63(10): 2727–2738.

11.

WHO. Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals, http://whqlibdoc.who.int/publications/2009/9789241597494_eng.pdf (2009, accessed 11 August 2014).

12.

WHO. Baby-friendly hospital initiative, http://www.who.int/nutrition/topics/bfhi/en/ (2014, accessed 11 August 2014).

13.

NHS/UNICEF. Off to the best start. Important information about feeding your baby, http://www.nhs.uk/start4life/Documents/PDFs/Start4Life_Off_To_The_Best_Start_leaflet.pdf (2012, accessed 11 August 2014).

14.

WHO. International code of marketing of breast-milk substitutes, http://www.who.int/nutrition/publications/code_english.pdf (1981, accessed 11 August 2014).

15.

Semper. http://www.semperbarnmat.se/produkter/fran-fodseln/babysemp-1 (2014, accessed 11 August 2014).

16.

Kukla

. Measuring mothering. Int J Femin Approaches Bioeth 2008; 1(1): 67–90.

17.

Kukla

. The ethics and cultural politics of reproductive risk warnings: a case study of California’s Proposition 65. Health Risk Soc 2010; 12(4): 323–334.

18.

Schmied

Barclay

. Connection and pleasure, disruption and distress: women’s experience of breastfeeding. J Human Lact 1999; 15: 325–334.

19.

Lamontagne

Hamelin

St-Pierre

. The breastfeeding experience of women with major difficulties who use the services of a breastfeeding clinic: a descriptive study. Int Breastfeed J 2008; 3: 17.

20.

Watkins

Meltzer-Brody

Zolnoun

. Early breastfeeding experiences and postpartum depression. Obstet Gynecol 2011; 118(2 Pt 1): 214–221.

21.

Tronto

. Moral boundaries: a political agreement for an ethic of care. New York: Routledge, 1994.

22.

Ruddick

. Maternal thinking: towards a politics of peace. London: The Women’s Press, 1990.

23.

Held

. The ethics of care: personal, political and global. Oxford: Oxford University Press, 2007.

24.

Noddings

. Starting at home: caring and social policy. Los Angeles, CA: University of California Press, 2002.

25.

Nihlén Fahlquist

Roeser

. Nuclear energy, responsible risk communication and moral emotions: a three level framework. J Risk Res. Epub ahead of print 11 September 2014. DOI: 10.1080/13669877.2014.940594.

26.

Hansson

. Weighing risks and benefits. Topoi 2004; 23(2): 145–152.

27.

Stuebe

. The risks of not breastfeeding for mothers and infants. Rev Obstet Gynecol 2009; 2(4): 222–231.

28.

Kahneman

. Thinking fast and slow. New York: Farrar, Straus and Giroux, 2011.

29.

Thaler

Sunstein

. Nudge: improving decisions about health, wealth and happiness. London: Penguin Books, 2008.

30.

Faden

. Ethical issues in government-sponsored public health campaigns. Health Educ Q 1987; 14(1): 27–37.

31.

Rossi

Yudell

. The use of persuasion in public health communication: an ethical critique. Public Health Ethics 2012; 5(2): 192–205.

32.

Buchanan

. Autonomy, paternalism, and justice: ethical priorities in public health. Am J Public Health 2008; 98(1): 15–21.

33.

Socialstyrelsen [Swedish National Board of Health and Welfare]. Amning och föräldrars rökvanor [Breastfeeding and the smoking habits of parents]. Stockholm: Sveriges officiella statistik [Sweden’s Official Statistics], 2014, http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/19537/2014-9-37.pdf (accessed 14 October 2014).

34.

Gwyneth

. Withholding and withdrawing treatment: Practical applications of ethical principles in end-of-life care. S Afr J Bioeth Law 2008; 1(1): 24–26.